Asthma Action Plan

Asthma Action Plan
STUDENT INFORMATION
Student's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Grade*
Homeroom Teacher or Class*
Physical Education Days and Times*
EMERGENCY INFORMATION
Mother/Guardian Name*

Mother's/Guardian's First NameMother's/Guardian's Last Name
Mother/Guardian Home Phone*
Please enter a valid phone number.
Mother/Guardian Cell Phone*
Please enter a valid phone number.
Mother/Guardian Work Phone
Please enter a valid phone number.
Mother/Guardian Email*
example@example.com
Father or Guardian Name*

Father's/Guardian's First NameFather's/Guardian's Last Name
Father/Guardian Home Phone
Please enter if different from Home Phone above.
Father/Guardian Cell Phone*
Please enter a valid phone number.
Father/Guardian Work Phone
Please enter a valid phone number.
Father/Guardian Email*
example@example.com
Physician's Name*

First NameLast Name
Physician's Phone*
Please enter a valid phone number.
In Case of Emergency, Contact
Contact 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Contact 3

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Asthma Emergency Action Plan
The following are possible signs of an asthma emergency:
- Difficulty breathing, walking or talking
- Blue or grey discoloration of the lips or fingernails
- Failure of medication to reduce worsening symptoms
These signs indicate the need for emergency medical care. The steps that should be taken are:
- Activate the emergency medical system in your area; Phone: Area Code* Phone Number*
- Call parent/guardian or physician
Triggers:*
Personal Best Peak Flow*

All Current Medications

	Name of Medication	Dosage	Time
1
2
3
4

Medications To Be Given at School (if any)

	Name of Medication	Dosage	Time
1
2
3
4

Steps for an Acute Asthma Episode

To be completed by Physician
Please list steps below*
Physicians Signature*

Clear
Date*

MonthDayYear
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Asthma Action Plan

STUDENT INFORMATION

EMERGENCY INFORMATION

In Case of Emergency, Contact

Asthma Emergency Action Plan

Steps for an Acute Asthma Episode